Triple Stapling Resection and J pouch anal Stapling Anastomosis for Ulcerative Colitis

Background: In 2017, we reported laparoscopic total proctocolectomy with J pouch anal anastomosis, which was created at the dentate line by our original procedure using staplers, Triple Stapling Resection and J pouch Anal Stapling Anastomosis (TSRJASA), for ulcerative colitis (UC) patients. UC patients have undergone TSRJASA since it was introduced in our institution. However, the feasibility and usefulness of TSRJASA for UC patients has not been elucidated.Methods: From January 2014 to December 2018, fourteen patients with ulcerative colitis, including three cases of concomitant cancer, who underwent TSRJASA were enrolled in this study. Anal manometry was performed using the Pock Monitor GMMS-100 system (STAR MEDICAL, INC., Tokyo, Japan) one year and two years after surgery. Maximum resting pressure, maximum squeeze pressure, and the length of the high-pressure zone were measured. Fecal incontinence was evaluated using the Wexner incontinence questionnaire.Results: J pouch anal anastomosis was created at the dentate line in all patients. In a manometric examination two years after surgery, maximum resting pressure was 75.3 (54-88) mmHg, maximum squeeze pressure was 125.0 (90-160) mmHg, and the length of the high-pressure zone was 39.6 (35-42) mm. Wexner score was 2.8 (1-4).Conclusion: TSRJASA seems to be a useful procedure for UC patients given its acceptable defecation function.

Early Results of Fissurectomy and Advancement Flap for Resistant Chronic Anal Fissure without Hypertonia of the Internal Anal Sphincter

The aim of this study was to assess the efficacy of fissurectomy with skin advancement flap in healing chronic anal fissures without hypertonia of the internal anal sphincter. Twenty-six consecutive patients who failed healing after well-practiced topical medical therapy were enrolled. Anorectal manometry was performed preoperative and 6 months postoperatively. All patients were treated with fissurectomy and advancement flap through healthy skin tissue. All patients healed completely within 30 days from operation. The intensity and the duration of pain post-defecation was reduced significantly with respect to the preoperative values starting from the first defecation. One patient suffered urinary retention, two patients suffered infections, and two partial breakdowns were recorded. At 6 months the maximum resting pressure values were similar to those were detected preoperatively. One month after surgery, anal incontinence was reported in seven patients, four of whom complained about it preoperatively. At 12 months, only three subjects reported incontinence. No patients needed reoperation and no recurrences were detected. The fissurectomy, in combination with advancement flap, is a safe sphincter-saving procedure for the treatment of chronic anal fissures without hypertonia of internal anal sphincter that fails medical conservative treatment.

Pouch Surgery — The Importance of the Transitional Zone

Patients with preservation of the transitional zone of the anal canal have less leakage and less need to wear pads than patients who have had mucosectomy. There is a significant difference in mean maximum resting pressure between patients that have had anal transitional zone preservation and mucosectomy. With preservation of the anal transitional zone, a mean maximum resting pressure of 57.6±3.8 mmHg was obtained compared with 47.3±4 mmHg in the mucosectomy group. Preservation of the resting pressure is dependent on preservation of internal anal sphincter integrity. The integrity of the sphincter is injured during mucosectomy due to anal dilation. Other factors affecting continence and stool frequency, such as diet, antidiarrheal medications, stool consistency and compliance, when examined were found to be unrelated factors.